Lukanen, Elizabeth
Zylla, Emily

Unwinding Ends, but States’ Reporting of Medicaid Renewal Data Continues (SHVS Cross-Post)

The following Expert Perspective (EP) is cross-posted from State Health & Value Strategies. Authors: Emily Zylla and Elizabeth Lukanen, SHADAC

Original posting date August 13, 2024. Find the original post here on the SHVS website.

States have resumed their regular processes for renewing individuals’ Medicaid and Children’s Health Insurance Program (CHIP) coverage due to the end of the continuous coverage requirement set in place during the COVID-19 pandemic. During this unwinding period, advocates, policymakers, and the media have been keenly interested in understanding how this work has impacted coverage for Medicaid enrollees.     

One key source of data has been the monthly Unwinding Data Reports that state Medicaid agencies were required to submit to the Centers for Medicare & Medicaid Services (CMS). These reports include indicators about activities related to eligibility renewals, call center operations, and transitions to Marketplace coverage; CMS began publicly reporting monthly snapshots of these data in August 2023. However, well before the federal government began reporting this unwinding data, many states began publishing their own state dashboards, publicly detailing their progress in restarting renewals.

The public release of renewal data, at both the federal and state level, has proven to be a valuable tool in understanding who lost Medicaid coverage and why during the unwinding. States have successfully used the data to both monitor renewal outcomes and adjust outreach and administrative enrollment policies. This data has also provided new transparency into state eligibility and enrollment processes that had previously been lacking.

CMS initially indicated it would report unwinding data only through June 2024 (the official end of the unwinding period). However, many states received CMS approval to extend timelines to complete their unwinding-related renewals. Subsequently, a May 30, 2024, State Health Official (SHO) letter announced that starting July 1, 2024, CMS will expect all states to continue to submit certain metrics contained in the Unwinding Data Report on an ongoing basis, now referred to as an “Eligibility Processing Report.” 

These reports will include monthly data on:

• Renewals initiated.
• Renewals due.
• Successful renewals, including the number renewed on an ex parte basis and through pre-populated renewal forms.
• Coverage terminations due to both ineligibility and procedural reasons.
• Pending renewals and renewal backlogs.
• Fair hearing requests pending for more than 90 days.

In the SHO letter CMS also explicitly encourages states to continue state-level transparency processes, including public dashboards that “can support ongoing state-level efforts to ensure timely processing of applications and renewals.”

States Publicizing Medicaid Renewal Data

During the unwinding period, the State Health Access Data Assistance Center (SHADAC) tracked which states were publicly reporting unwinding data (separate from their required CMS monthly report). Over the course of the official unwinding period, from April 2023 through June 2024, 45 state Medicaid agencies (including the District of Columbia) regularly published their own renewal data (reflected in the map above), either in an interactive dashboard or a static PDF format. Two states, Mississippi and West Virginia, made copies of their monthly CMS data unwinding reports available on their state websites, but did not publish any additional state-level renewal or unwinding data. Four states, Alabama, Florida, Hawaii, and Wyoming, did not publish any state-level data.

Although some states, such as Arkansas, Idaho, Montana, and Utah, have indicated that they will no longer be updating their state unwinding dashboards, the majority of states appear to be maintaining and posting regular data updates. Other states, such as Virginia, have indicated that they plan to incorporate some of the information from their unwinding dashboard into an ongoing dashboard to track enrollment as a whole. 

Medicaid Reporting Bright Spots

Given the time-lags and caveats of the CMS data, state-level dashboards and/or reports became valuable sources of timely, up-to-date information for states, policymakers, and other stakeholders, allowing them to better understand how the unwinding progressed. States that published their own data also had the ability to provide additional detail about definitions, varying timeframes, and state-specific context important for communicating the unique circumstances that they experienced during unwinding.

In addition, although CMS only required states to report data broken down by modified adjusted gross income (MAGI) and non-disability applications versus disability applications, many states were able to supplement their federal reporting with both state-specific data analysis and data broken down by eligibility group and other demographic characteristics (e.g., age, race, ethnicity, language, geography). These types of additional data breakdowns helped elucidate important trends about the disproportionate impact of the unwinding on groups that have been economically or socially marginalized.

Several states also reported how many individuals were reinstated in Medicaid after a termination, thus providing a more complete story about what happened to individuals after they were disenrolled from Medicaid.

Among state Medicaid agencies’ unwinding dashboards or reports, several stood out.

Indiana Family and Social Services Administration – Medicaid Renewals and Outcomes Dashboard

Indiana’s dashboard provided a highly visual and interactive interface for the user. Renewal outcome data was filterable by geography, race and ethnicity, gender, age, program type, and managed care entity. Renewal outcomes were displayed both as total counts and percentages.

Kentucky Cabinet for Health and Family Services – Medicaid Unwinding Demographic Reports

Kentucky was one of the earliest reporters of state-level unwinding data, publishing data snapshots beginning in April 2023. Kentucky additionally began publishing Data Demographic Reports on a monthly basis beginning in September 2023, which provided breakdowns by race, ethnicity, age, gender, and county of residence, of Medicaid renewals, pending cases, and terminated cases.

Massachusetts Executive Office of Health and Human Services – MassHealth Eligibility Redetermination Dashboard

Massachusetts’ dashboard, updated on a monthly basis, provided data on member renewals and departures, filterable by age, program type, disability status, and whether the member resides in a “priority community” (i.e., one of the top 15 towns or cities where the most MassHealth members were at risk of losing coverage). Massachusetts also reported the number of terminated members who re-enrolled in Medicaid after a specific period of time.

Nevada Department of Health and Human Services – Monitoring Medicaid Enrollments, Disenrollments, and Renewals in Nevada Dashboard

Nevada’s dashboard displayed historical enrollment data both prior to and during the public health emergency (PHE). It also contained detailed metrics of the demographic characteristics for individuals disenrolled from Medicaid, including a comparison of the distribution of the disenrolled population versus the enrolled population. This visual display of differences between the two groups made it especially clear to see how disenrollments were affecting certain demographic groups more than others. 

Oregon Department of Human Services – Medical Redeterminations Dashboard

Oregon’s dashboard displayed the number of renewals due each month as well as the number of renewals that were completed, initiated, or not started. The dashboard also presented data disaggregated by written language, gender identity, race and ethnicity, age, disability status, housing status, county, and reason for closure. Oregon also published a separate dashboard for call center data, including a daily average customer service score.

State-Based Marketplace Reporting

State-Based Marketplaces (SBMs) also played a significant role during the unwinding by coordinating with Medicaid agencies and using a number of different strategies to ensure a smooth transition for people who no longer qualified for Medicaid and were eligible for a qualified health plan (QHP) offered through the Marketplace. Given this, policymakers, advocates, and the media have also been keenly interested in unwinding data on the outcomes of transitions from Medicaid to the Marketplace.

By the end of the unwinding, 16 of the 19 states that operate an SBM had reported some data on Marketplace transition outcomes (see Table 1 below). In some states, this information was reported by the SBM itself, and in other states, Marketplace transition outcomes were included within the state’s Medicaid renewals dashboard. In 11 states, this meant ongoing reporting as part of a formal and easy to find data dashboard or data repository. In five states, Colorado, Idaho, Kentucky, Maine, and Washington, data was reported less consistently – examples include reporting as a part of SBM board meeting minutes or administrative documents, or as a part of a one-time or sporadic release of information. Three SBMs, the District of Columbia, New Mexico and Virginia, did not publicly report Marketplace transition data. Virginia, however, launched its SBM on November 1, 2023 and while the state was using the Federally-Facilitated Marketplace (FFM) at the beginning of the unwinding, CMS was responsible for the states’ reporting of transition data.

Table 1. Reporting of State-Based Marketplace Transition Data

Generally, reporting of SBM data was more limited and less consistent across states than Medicaid reporting. All of the states listed in the table above reported enrollment in a QHP by people no longer enrolled in Medicaid. Only one SBM, Idaho, reported a conversion rate (i.e., Marketplace enrollment among those disenrolled from Medicaid) and about half of the SBM states reported elements allowing for this calculation (however, it is important to note that often these data points were hard to find). Six SBM states reported information about whether transitioners received premium assistance, and only two states, California and Washington, reported transitioner demographics. 

Along with this data reported by SBMs, CMS also released state Marketplace enrollment transition data. These data included information on consumers who:

• Were transferred to or applied for Marketplace coverage.
• Were eligible for a QHP or Basic Health Plan (BHP) coverage (disaggregated by those eligible for financial assistance).
• Had a QHP selection or BHP enrollment.

CMS data was reported differently for FFM states that use HealthCare.gov, and for SBM states with an integrated system versus those who transfer accounts between Medicaid and the Marketplace.

While CMS data offered a somewhat parallel view of progress in all states, it was released at a lag (compared with state reported data) and comparability was complicated by data concerns and cautions regarding state comparisons, differences in how states managed changes to ex parte renewals, and potential confusion regarding the use of different denominators. Although CMS is requiring states to report ongoing Medicaid enrollment and renewal metrics beyond the unwinding period, the May 2024 SHO letter indicated that states will no longer have to report SBM transitions starting June 30, 2024, or once the state has completed all unwinding-related renewals (whichever is later).

SBM Reporting Bright Spots

While most SBM states offered transparency regarding unwinding transitions by releasing outcomes data beyond required CMS reporting, variation in how data were reported, their specific definitions, reporting timelines, and disaggregation made it very difficult to compare similar measures across states.

That said, like the Medicaid unwinding dashboards, individual SBM reporting allowed states to present the most current data available in the context of their broader unwinding efforts – controlling the narrative and storyline. In other words, states could report more quickly, and they could present Marketplace and Medicaid data together offering a holistic view of the impact of the unwinding. States could also publish disaggregated data, beyond the requirements, such as transitioner race/ethnicity and geography. States were also able to provide more detail on the metrics being released, providing clear data labels and definitions, methodologies and documenting data revisions. Among the SBM states reporting robust Marketplace transition data, several stood out.

Covered California Medi-Cal Transitioner Profile

California provided detailed data on Californians who transitioned from Medi-Cal to Covered California (the state’s official health insurance Marketplace) in the form of an Excel file. The Excel file has multiple tabs and contains counts, percentages, and detailed methodological and definitional information. It starts with a tab containing summary information on transitions by month (called “key performance indicators”). The tabs that follow contain detailed demographic information for: individuals who lost Medi-Cal and who were eligible for Covered California; those who lost Medi-Cal, were eligible for Covered California, and received an automatic plan selection; and those who effectuated QHP coverage. Demographic data available for those categories includes:

• Age
• Gender (including transgender identification)
• Income
• Race and ethnicity (in combination and separately)
• Written language
• Service channel used (i.e., Certified Insurance Agent, Certified Enrollment Counselor)
• Geography (i.e., region, county)
• Financial assistance

Pennsylvania Medicaid Continuous Coverage Unwinding Data Tracker

Pennsylvania had one of the earliest unwinding dashboards featuring Marketplace renewal outcome metrics. The dashboard presented side-by-side renewal outcome metrics for Medicaid and the Marketplace, providing a holistic view of coverage transitions across the state. In addition, the state provided information on the outcomes of transitions to Pennie (the state’s official health insurance Marketplace) by county and ZIP code. 

Washington Keeping People Covered During the Medicaid Unwind: Data Snapshot Reports

Washington released robust data snapshots in October 2023 and January 2024 (each available as a PDF). These reports started with summary information (called “data top lines”), a personalized coverage transition example illustrating an individual’s cost under a QHP, and detailed information on coverage transitions such as the geographic distribution, carrier transitions, receipt of financial assistance, and demographics of transitioners (i.e., age, sex, race, and ethnicity). Washington provided both counts and percentages for most data points and provides a detailed appendix with information on data sources and definitions.

Conclusion

Timely, accessible, state-level data on Medicaid renewal outcomes will continue to be important for understanding the impact of various policies on Medicaid enrollees, even after the unwinding period ends. Given the ongoing reporting requirement from CMS, and states’ success setting up these new public reporting capabilities, there is hope that states will continue to make detailed disenrollment, renewal, call center, and Marketplace transition data publicly available on an ongoing basis.